STUDENT PROFILE SHEET - DOC by callmemelo

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                               STUDENT PROFILE SHEET
Information from this sheet is used, in part, for admission decisions. To enhance your
chances for admission the student should thoroughly and honestly complete this form.
In addition selected students should update it each semester. The information included
here may be used to nominate/select students for: Competitive scholarships, Who's
Who Among Students in American Universities and Colleges, Student Honor Award for
SAHS, Alpha Eta, and the Departmental Outstanding Student Awards.

EXCEPT FOR SIGNATURES PLEASE TYPE OR PRINT TO COMPLETE THIS FORM

NAME __________________________________________________________
          (last)                (first)               (full middle)

Social Security Number: __ __ __- __ __ __- __ __ __ __

ADDRESS AND TELEPHONE NUMBER:
        CURRENT ADDRESS               PERMANENT ADDRESS
Street:                       Street:

City:                                            City:

Country:                                         Country:

ZIP or postal code:                              ZIP or postal code:

Phone:                                           Phone:
Day: (   )                                       Day: (     )
Evening:

DEPARTMENT = PHYSICAL THERAPY
  Current Status (check ) Today’s date                                 Date Revised
Applying for DPT                                                   XXXXXXXXXXXXXXXXX
*First Year
*Second Year
*Third Year
* Complete these sections during your enrollment in the program.

If you have questions on how to complete this document, please check with the chairperson for physical
therapy admissions or your faculty advisor. If additional space is needed to complete any section use
separate sheets. Be sure to use the same format as the original form. Thank You,

I hereby attest that the information contained on this form is true to the best of my
knowledge.
Signature___________________________ Date ___________________
                                                                                       2


STUDENT PROFILE SHEET                    SS#: __ __ __- __ __ __ - __ __ __ __

COLLEGES/UNIVERSITIES PREVIOUSLY ATTENDED AND DEGREES RECEIVED
  College or University  Degree (if applicable) Dates of attendance




HONORS AND AWARDS RECEIVED - since high school - (Examples: Dean's List,
Who's Who, Scholarships, and other academic and non-academic awards; please
indicate dates and conferring institution, group, agency or organization).
     Name or Type of                   Conferring                  Date of Award
      Honor/Award              Institution/Agency/Group




PROFESSIONAL MEMBERSHIPS AND INVOLVEMENT (Examples: participation in
local, state, and national associations; serving on committees for same; publications;
presentations.)
   Activity/Position     Association/Group       Dates of Service     Amount of Time
                                                                     Devoted to Activity
                                                                                        3

STUDENT PROFILE SHEET              SS#: __ __ __- __ __ __ - __ __ __ __

COMMUNITY INVOLVEMENT - since high school - (Examples: involvement with
health organizations; community organizations; church activities; volunteer work,
political campaigns, community sports.)
Association/Group            Type of         Dates of Service         Amount of Time
                         Activity/Position                           Devoted to Activity
                        held (e.g. officer,
                       member, committee
                        chairperson, etc.)




ADDITIONAL RESPONSIBILITIES AND COMMITMENTS (Examples: employment and
personal commitments; please give dates):
Brief Description of Responsibility or Commitment  Dates over which
                                                   responsibility
                                                   occurred.




Please return this form when completed to: Office of the Registrar, 301 University Blvd.,
Galveston, Texas 77555-1305

								
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